0208 (BLCK)PERMIT APPLICATION
City of La Dulnta
Department, of Building and'. Safety
This permit becomes void if work not commenced within 180 days from date otissuance. OR, if work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions,Code, and my license is in full force
and effect.
License Class
Date Contractor
Lic. Number
OWNER -BUILDER DECLARATION; I hereby affirm that I,am exempt from the Contractor's License Lawlor the
following reason (Sec. 7031:5, Business and Professions Code: Any city or county which requires a permitto
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter -9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged ezemp,tion.Any violation o1, Section 7031.5 by any applicant for a permit
subjects the:appiicani to a civil penalty of not more than five hundred dollars ($500.):
0 I, as owner of thaproperty, or my employees.with wages as their sole compensation, will do the work; and the
structure is notintended proffered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
through his own employees, provided that such improvements are not intended or offered forsale. If, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
0. L as owneeof the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builps or improves thereon, and who contracts for such projectswith a contractors) licensed pursuant to the
Contractor's. License Law.).
0 1 am exempt under Sec.
Owner
. B. E P.C. (Attached Certificate)
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I'have a certificate of consent.to self -insure, ora
certificate of Workers' Compensation Insurance ,.or a,certified copy thereof (Sec. 3800. Lab. Q.
Policy No. Company
0 Certified copy is hereby furnished.
0 Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT M (L, F. MI)
ADDRESS
CITY/COMMUNITY/STATE/ZIP .,i /�
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JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
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TRACT NAME
OWNER NAME IL, F, Mn 5�xe
CONTRACTOR -FIRM NAME
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ADDRESS VJ —,I
CITY/COMMUNITY/STATE/ZIP %
PHONE a
My
'LICNC e
ARC/ENG FIRM, NAME
ADDRESS
CITY/COMMUNITY/STATE/ZtP
PHONE e e
LICNC e
USE OF PERMIT
BL
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Fee
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ZONE ORD a
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END
SIDE
Arrow Printing, 250/1.83
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less.] certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California. j/
Dat@_` .Applicant, fn
NOTICET'0 APPLICANT:: IL after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the LaborCode, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
11 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be
made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than.thirty-six (36) feet high. (Chap 3.2, Grp 2, Art2. Sec341, Titlell,
CAC.)
0 As owner -builder, I' will',not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as holed above, unless such person has a permit to do such work from that division.
❑'Division of Industrial Safety Permit No.
Applicant
CONSTRUCTION LENDING AGENCY: 1 hereby affirm that there is a construction lending agency for the performance
of the work for which this permitis issued (_Sec. 3097, Civ. Q.
Lender's Name
Lender's Address
I certify. that I have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND, AUTHORIZATION OF ENTRY: '1 certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction,; and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which I have, applied for this permit for the purpose of making inspections.
I `W Signature of Applicantor Agent % r ♦ Date
Print Applicant/Agent Name
APPUPRMT A
p
16 x...11, t-1 A ! VV/ , 0
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10
My
TFEE
White: Finance Canary:, Assessor Pink: Applicant Tag: Bldg. Dept.
VALUATION
NO.
OPERATION DATE
INSPECTOR
NO,
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS ,
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab .Grade
35
Furnace Compart.
3
Steel
36
Inlets& Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof'°Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9-
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
fireplace T.O.
❑
NPON
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE &LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL Pi
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
r -
M
6